1629167986 NPI number — UROLOGICAL ASSOCIATES OF BELLEVILLE IL LTD

Table of content: (NPI 1629167986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629167986 NPI number — UROLOGICAL ASSOCIATES OF BELLEVILLE IL LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UROLOGICAL ASSOCIATES OF BELLEVILLE IL LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629167986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 W LINCOLN ST STE 57
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62220-1901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-233-2603
Provider Business Mailing Address Fax Number:
618-233-0413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 W LINCOLN ST STE 57
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62220-1901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-233-2603
Provider Business Practice Location Address Fax Number:
618-233-0413
Provider Enumeration Date:
10/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STANCZYK
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
JEROME
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
618-233-2603

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 289630 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".